Author: afternoonrounds

The keto diet has been widely promulgated as an effective therapy for the treatment of diabetes and weight loss with minimal side effects. Many discussions regarding the diet present an unbalanced view, often omitting studies that show harm or lack of a benefit. To balance the narrative, I’ve written this post that I intend to keep maintained for foreseeable future. Below I present the links to references of important studies that are often excluded from the discussion of ketogenic, and by association, low-carbohydrate diets. I invite you to look through them. Personally, I did not expect to find as much as I did (and certainly not so many concerning side effects). If you have other studies or comments, please post them below in the reply section of this page. You can also share them with me on Twitter @sjoshiMD.

Finally, further illustrating the point of the decreasing difference between glycemic levels as time goes on (likely a result of difficulty of complying with the diet and lack of any effect on the pathophysiology of diabetes), a meta-analysis of randomized-controlled trials lasting a year did not show any benefit in fast plasma glucose or glycosylate hemoglobin levels

The claims of abundant weight loss are not substantiated with high-quality research

What is the point to the diet if there is only 2 pounds of weight loss after one year?

To put this in perspective, this is the amount of weight you would lose if you ate 19 less calories per day for an entire year (roughly).

Mutation Among Inuit to Avoid Ketosis

The Inuit of the Arctic consumed a diet high in fat given their dependence on marine mammals with blubber and high amounts of adipose tissue. One would expect that this type of diet, given the lack of carbohydrates, would induce ketosis. However, the Inuit of Greenland and Canada actually have a mutation to avoid ketosis.

The mutation can have deleterious consequences if the Inuit are not able to obtain energy from other sources since ketone bodies are a source of energy. Unsurprisingly, the mutation increases the risk of hypoketotic hypoglycemia, which increases the risk of death, especially in infants.

The plot thickens: Despite the deadly risks of the mutation, more than 80% of Greenland and Canadian Inuit have the mutation. Why? Why would evolution favor the propagation of a deleterious mutation? The only reason is if the alternative was worse.

Some have theorized that ketosis is not likely a wise a long-term strategy for survival. The ketogenic diet can cause metabolic acidosis (see below) from the production of acidic ketones, which lowers the pH. In times of stress (like illness, trauma, starvation, cold weather?, etc.), the blood can become even more acidic (lower pH) and increase the risk of death. Situations like this might have favored the spread of a mutation to circumvent ketosis in the Inuit.

Claim that the Ketogenic Diet Drastically Increases Metabolism

Keto enthusiasts often tout the diet as unique because of its ability to significantly increase the metabolic rate. Not only is this not true, in some cases, it is actually the opposite of what was found in scientific studies.

Researchers at the NIH have shown that low-fat diets (like a whole-foods plant-based diet) actually result in more fat loss than low-carb diets (e.g. the keto diet).

The low-carb diet did lose more total weight but this study shows that this weight was from lean tissue (muscle) loss and water loss, and not loss of fat (the opposite of what is generally desired).

Other studies have also shown the sizable amount of water lost with the ketogenic diet, which is regained once the ketogenic diet is stopped.

It has been hypothesized that the ketogenic diet can increase energy expenditure by a whopping 400-600 calories per day. In a scientific study, researchers found that the increase energy expenditure in the ketogenic diet was much smaller and approached the limit of science to detect the increase. In addition, fat loss was lesscompared to those on a high-carb diet. Finally, those eating a ketogenic diet had more water and lean body mass loss than those eating a low-fat, high-carb diet.

Documented Side Effects of the Ketogenic Diet from the Pediatric Epilepsy Literature

I wrote this article for a senior Indian-American audience in Upstate New York. I share it here as the main points are applicable to all of my readers, regardless of age or ethnicity.

Kidney disease is no stranger to Indians. It affects nearly 1 in 10 people in India and even a higher number for those who come to America. The high rate of kidney disease is thought to be due to the higher rates of high blood pressure and diabetes in our demographic. Because of this, it is important to take an active approach to preventing, treating, and reversing these diseases, especially as they relate to kidney disease. Once your kidneys are gone, the options become limited.

Diabetes

Diabetes takes its toll on every part of the body with the kidneys being no exception. Diabetes is the number one cause of kidney failure for both Americans and Indian-Americans, but diabetes occurs at a higher rate in the Indian community than the average American due partly to our propensity for developing the disease and mostly to our dietary habits that include foods high in sugar, fat, and calories; gulab jamun may be tasty, but it isn’t particularly healthy. Up to a third of patients with diabetes don’t know they have it, which is why it is important to be screened periodically, especially if you are overweight. For those afflicted, it is important to lose weight, exercise daily, and eat a diet with plenty of fruits and vegetables. These recommendations also apply to the second most common cause of kidney failure: high blood pressure.

High Blood Pressure

High blood pressure, or hypertension, puts a strain on the kidneys causing scarring and damage over the years. Like diabetes, many with high blood pressure don’t know they have it–up to half of those affected. Checking your blood pressure can easily be done at a doctor’s office, a health fair, or at home with a portable blood pressure machine. Those who have high blood pressure should limit their salt intake along with other parts of a “bad” Indian diet, like ghee, fried foods, and sweets. Replacing these items with fruits, vegetables, lentils, and beans is crucial to having a normal blood pressure. As with diabetes, losing weight, exercising, and seeing a physician regularly can reduce your risk of kidney disease from high blood pressure.

Medicines

Any discussion of kidney disease in Indians needs to include the risk of medicines, specifically Ayurvedic medicines. Ayurvedic medications can include heavy metals, like gold, mercury, lead, arsenic, and cadmium, all of which are particularly toxic to the kidneys. For those on Ayurvedic medicines, it is best to consult with your physician on how to avoid exposure to these heavy metals. Another danger is the class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs), which reduce blood flow the kidney and can cause damage with repetitive NSAID use. Those using NSAIDs–like naproxen and ibuprofen, among others–should minimize the use of these medications and avoid being dehydrated when they are used. Finally, if you are on medications for diabetes or high blood pressure, it is important to take them as prescribed by your doctor.

Summary

We have been blessed to have two kidneys, but, for some, two kidneys are still not enough. Too many patients end up with kidney failure, requiring dialysis or transplantation–options that are not as good as preventing kidney failure in the first place. Fortunately, for most of us, kidney failure can be prevented by avoiding the damage of high blood pressure and diabetes and using medications judiciously. By making the right decisions over a lifetime, two kidneys can be more than enough.

I recently wrote a letter to the editor to JAMA Internal Medicine on the article posted above. The editors rejected it, but I’ve posted it here for your viewing pleasure.

Dr. Curfman recently highlighted the lack of benefit of ω-3 fatty acids in recent studies, despite their initial promise, in the secondary prevention of cardiovascular disease. His editorial also mentions the American Heart Association’s recommendation that adults consume fish at least twice weekly and himself concludes with similar advice for his readers.

The consumption of fish on a regular basis was brought to the forefront because of the ω-3 fatty acids within fish oil and their presumed beneficial properties on cardiovascular health, as Dr. Curfman mentioned. However, subsequent studies, including large meta-analyses using endpoints like all-cause mortality and primary prevention of cardiovascular disease, have failed to show any benefit of ω-3 fatty acids. Additionally, one of the original studies, the DART-2 trial, even showed a statistically significant increase in sudden cardiac death with increased fish oil consumption.

The continued consumption of fish is all the more concerning given the elevated concentrations in fish of toxic substances like polychlorinated biphenyls (PCBs), mercury, lead, cadmium, and dioxins, all of which can adversely affect human health. Additionally, a meta-analysis of fish consumption has shown that a single serving of fish in the U.S. per week has been associated with an increase in the risk of diabetes, possibly from the PCBs or mercury, or both. Further, both childhood and current consumption of fish has been shown to decrease cognitive performance in older Americans, who are most likely to suffer from cardiovascular disease. Until we have strong, compelling evidence on the health benefits of fish or fish oil, it may be safer to avoid its consumption entirely or obtain fatty acids from sources with lower concentrations of pollutants, like algae.

This article was written prior to Puzder’s withdrawal of his nomination as labor secretary. I am well aware that he is no longer the nominee, but have posted the article for its points on the minimum wage and public health.

President Trump’s nomination of Andrew Puzder, the current CEO of the company that operates Hardee’s and Carl’s Jr., for labor secretary is not only a poor choice for protecting the American workforce, but also undermines important public health issues that have their roots within the fast-food industry. Puzder has notoriously opposed increases in the minimum wage and paid sick leave, both of which have impacts on healthcare at a national level.

Addressing the economic pitfalls of a minimum wage hike is the first step in addressing the public health concerns associated with minimum wage workers, as any public health measure will likely not take hold if it is thought to be financially untenable. Puzder has tritely argued that raising the minimum wage will reduce jobs, slow the economy, and hurt workers, when, in reality, none of which have actually happened during the nearly two dozen times the minimum wage has been increased. Ironically, the Department of Labor’s own website features a “Minimum Wage Mythbusters” webpage debunking common arguments against any federally mandated pay increase, which might be of benefit for Puzder to read for the office he may soon take over–at least before it disappears like other federal websites unfavorable to the new administration.

Not only have increases in the minimum wage created jobs in most cases, but they have also been shown to improve health outcomes. In a 2014 analysis examining the effects of a wage increase in California, researchers found that increasing the minimum wage would decrease the rates of hunger, smoking, obesity, premature death, depression, and bipolar illness. The results are not surprising as minimum wage workers are living paycheck to paycheck and any additional disposable income might then be used towards important health-related costs, including food, medications, and copays.

Unsurprisingly, minimum wage fast-food workers depend heavily on public benefits, like Medicaid, food stamps, and the earned income tax credit. According to a 2013 study by the Center for Labor Research and Education at the University of California-Berkeley, fast-food worker subsidies amount to nearly $7 billion a year–of that, of which an estimated $247 million goes to the workers of Puzder’s Carl’s Jr. and Hardee’s annually. A raise in the minimum wage could translate into savings of billions of dollars that could be used for other government services, like other public health measures.

Raising the minimum wage seems like the obvious choice when considering the cost to consumers: only two cents to every burger purchased for every dollar added to the minimum wage. Thus, raising the minimum wage by two dollars would add less than a nickel to a Hardee’s Thickburger.

Another seemingly obvious public policy measure is giving restaurant workers paid sick-leave when they are sick. Restaurant workers, who are already stretched thin, shouldn’t be compelled to work during illness for fear of financial ruin. The Centers for Disease Control estimates that nearly 48 million people–1 in 6 Americans–are sickened by a foodborne illness each year, with 60% of outbreaks starting within restaurants. Having a restaurant worker be sick, it turns out, is the single most common cause of an outbreak, which can be mitigated by having paid sick-leave for workers. It’s a policy Puzder might have already taken note of: In 2015, more than 3,700 people were treated for possible exposure to a foodborne illness after eating from two South Carolina Hardee’s where one of the employees was infected with Hepatitis A.

Puzder’s nomination for labor secretary reminds us of George Orwell’s concept of doublethink–where the offices entrusted with protecting us may actually be hurting us. It may be one reason why so many of Hardee’s and Carl’s Jr. employees have protested his nomination. In addition to being anti-labor, his policies are decidedly anti-health, which is why the Center for Science in the Public Interest has also decried Puzder’s nomination. Lest anyone had forgotten the obvious, Puzder’s Hardee’s is the home of the 2/3rd pound Monster Thickburger, a dietary abomination with 1,340 calories, 96 grams of fat, 34 grams of saturated fat, 275 grams of cholesterol, and 3,130 grams of sodium. To say the least, Thickburger policy will not be making anyone healthier under Puzder’s reign.

There has been on average one mass shooting (involving at least 4 people) for every day this year. In the wake of the San Bernardino shooting – the most recent widely-covered mass shooting, America has reopened the debate over gun control, pitting a bereaved public beckoning for gun reform against rifle-thumping, strict-Constitutionalists. Yet, in this polarizing debate filled with a seemingly binomial future, there are other options: namely those that focus on common-sense public health measures, like repealing the federal ban on gun research and physician gag laws.

Guns kill more than 33,000 people a year. Guns kill more than double the number of Americans compared to AIDS each year. With such a heavy toll, gun-related deaths are epidemic in America. As with any other epidemic, one would expect the federal government to fund research on the causes and treatments of such a scourge on society – except with the case of guns. Since 1997, the Centers for Disease Control and Prevention (CDC) has been explicitly prohibited by Congress from using taxpayer dollars to study something that kills more than 90 people a day. As described in an article in the Journal of the American Medical Association after the 2012 Sandy Hook massacre, the action stems from an irrational fear that saving lives is equivalent to forfeiting essential American values – the act is reminiscent of 1950’s paranoia where a glance askew was labelled as McCarthyism.

All efforts to have a meaningful impact on gun violence have been dead in the water for nearly two decades. More importantly, it has left the public without any “position” statements – guidelines that set the rhetoric for public health measures – to steer the public on safety. Instead, we are left to decide for ourselves, or worse, be swayed by an increasingly emotional debate on gun safety. If you’re confused if having more guns makes America safer or more dangerous, you should be. Here’s a study showing that guns increase crime, and here’s another showing the opposite. It would be nice if the CDC – with all of their resources – could separate the noise from the signal for us.

Another counterintuitive and inane bulwark of the pro-gun group is the institution of so-called “gun gag” laws. Florida was the first, and likely not the last, state to seemingly ban physicians from asking their patients if they owned a gun and if that gun was secured and out of reach of children. Although conversation on the topic is permitted if it is “medically relevant,” many physicians find the laws so restrictive that they chill any discussion on gun safety. Such seemingly common sense practices – practices that are routine for physicians – are now banned as a part of the hysteria that envisions British red coats returning America to the Queen. If my patient finds my questioning not “medically relevant” – even though it may be, I could be liable under Florida law.

Accidental injury from guns among children is a serious issue. A 2013 New York Timesarticle estimated gun accidents may be in the “top five or six” leading causes of unintentional deaths among children due to discrepancies in accidental death reporting. Several months ago, Darnal Mundy, a 3-year-old boy in Miami, FL, shot himself in the head while looking for an iPad. He had climbed onto a chair, reached into a drawer, found a gun, instead of an iPad, and shot himself in the head. After being in a coma for several weeks, Darnal survived and was released from the same hospital at which I work. But not all children are so fortunate, one study has estimated that nearly two children die every week from unintentional shootings alone.

According to the Children’s Defense Fund, more than 40% of gun owning households with children store their guns unlocked. Some of these households don’t know the basics of gun safety, and they may never know now given the emergence of gun gag laws. Safe storage of guns – another common sense public health measure – is supported by the American Academy of Pediatrics because it has been shown to be effective at reducing injuries. It is no surprise that the National Rifle Association, one of the most powerful lobbies in Washington, has opposed safe storage laws for guns because it would have rendered homeowners “defenseless and given criminals a clear advantage in home invasions.” I didn’t realize that locked guns had adversely affected public health so much that we should only keep guns unlocked.

Changing public health policy usually begins with solid research. If you are interested in reducing the number of preventable deaths and injuries from guns, you can begin by opposing the nonsensical ban on federal funding of gun violence research. If you are a non-physician, you can show your support here. If you are a physician, you can sign a similar ban here.

Several weeks ago, the World Health Organization (WHO) released its report condemning processed meat as a Group 1 human carcinogen – a classification that includes such notorious companions as tobacco smoking, smokeless tobacco, and second hand smoke. This is not surprising considering that processed meat contains many of the same known or probable carcinogens as cigarette smoke, like heterocyclic amines and N-nitrosamines. Red meat was labelled in the runner up category as a “probably causing cancer” – specifically colorectal cancer. The similarities between meat and tobacco also extend to how both of their industries have decried prestigious health organizations as they have issued reports aimed at improving public health and saving lives. Akin to the tobacco industry’s response several decades ago, the meat industry – using many of the tactics of Big Tobacco – swiftly denounced the WHO report.

Crying Foul

The first defense brandished by tobacco industry after the Surgeon General declared that cigarette smoking causes lung cancer in 1964 was denial. It was their most important tactic, and it served them well for decades. The industry maintained its position by creating doubt among the public. As a tobacco industry stated after the Surgeon General’s indictment on smoking, “Doubt is our product.” By creating controversy, the tobacco industry was able to defer a smoker’s need to quit smoking and preserve profits – at least until the “controversy” was settled, which took nearly three decades. In reality, among the public health community, there was never a controversy – only the one fomented by industry. At the time of the Surgeon General’s report, the average American smoked a half pack per day. Although smoking rates declined in the ensuing decades, the decline was mitigated by the industry’s aggressive tactics.

Borrowing a precedent set by the tobacco industry, the meat industry categorically denied the WHO’s landmark statement, calling it “dramatic and alarmist overreach.” The North American Meat Institute wasted no time in denying that meat causes cancer, arguing that “numerous studies” have shown “no correlation between meat and cancer.” By “numerous” they mean nine studies. In comparison, the WHO looked at more than 800 studies, from which they concluded that processed meats do cause cancer – a similar conclusion was reached by the American Institute for Cancer Research and the World Cancer Research Fund International after reviewing 7000 studies a few years ago.

Correlation is Not Causation and Other Fallacies

The industries’ best strategy to buttress their claims of denial is to argue that correlation is not causation. Simply put, just because both meat consumption and colorectal cancer rates are high doesn’t mean they are related. The industry will say that meat eating countries have a lot of power lines, for example, that could also be a cause. These are half-truths distorting basic statistical concepts to support an a priori claim. The reason the WHO concluded that processed meat cause cancer was because they looked at a wide body of evidence from multiple sources. They looked at evidence from animal studies, basic science research, and, of course, humans to see the whole picture. It was the totality of the evidence that led the WHO to eschew bacon.

It was the same approach that led public health authorities to rethink our relationship with cigarettes, which was made public with the Surgeon General’s report in 1964. In order to subvert the medical establishment, the tobacco industry created the “Tobacco Industry Research Committee” and several other decoy organizations with the express purpose of fostering claims that cigarettes do not cause cancer. These organization were filled with for-hire publicists, scientists, and physicians. In an example of organized knavery, they argued that heavy smoking was unrelated to rising rates of lung cancer and other causes were to blame – like air pollution, smoke, and automobile exhaust. We now know that smokers are 15 to 30 times more likely to get lung cancer or die from lung cancer than nonsmokers.

Examples of overt obfuscation have also occurred after WHO report debuted. House Republican and Agricultural Committee Chair Michael Conaway boorishly stated, “These claims are based on a biased selection of studies performed by an organization notorious for distorting and misconstruing data …” Although Mr. Conaway does not have any formal back ground in the medical sciences or statistics, he has received more than $350,000 in campaign support from the livestock industry, according to the Center for Responsive Politics.

In reference to the WHO’s report, the North American Meat Institute also did not mince its criticism, stating, “They tortured the data to ensure a specific outcome.” The diction is ironic and distasteful considering that the meat industry itself has been repeatedly accused of torturing animals in the process of making meat, as this PETA exposé narrated by Paul McCartney graphically illustrates.

Benefits Outweigh the Risks

Perhaps the only endorsement the meat industry can make at this point is one that appeals to popular conception: meat has a lot of protein (and that protein is good for you). In fact, that is exactly what the meat industry did: “Meat is ‘nutrient-dense’ and vital humans… Meat is a complete protein, meaning it contains all the amino acids our bodies need.” Yet, there are plenty of protein sources that are carcinogen-free, like beans, lentils, and tofu. In a land of plenty, there is no reason to risk cancer for the sake of protein. As a physician, I have yet to see anyone in America with a case of true protein deficiency (known as kwashiorkor).

Hormel, one of the leading meat processors, went on further to state the benefits of these nutrients outweigh any risk, the “very important nutrients in meat far outweigh any theoretical hazard.” This rhetoric of emphasizing value and discrediting the risks is not novel to the meat industry and was pioneered by Big Tobacco.

The tobacco industry used similarly deceptive advertisements throughout the 20th century to trumpet the benefits of smoking. These advertisements feature physicians whole heartedly endorsing cigarette smoking. As recently as 1988, the then CEO of Philip Morris, Joseph Cullman III, has been caught on record trying to discredit studies showing hazard to health by stating, “There is only a statistical association. It has never been proven.”

Quantifying the Risk

The meat and tobacco industry have a self-interest in preserving their profits, but you have also have an interest in preserving your own health. The choice to smoke or consume processed meat is an individual one, but should be made based on knowing all the facts. With both of these habits, we now can quantify our risk. With smoking, we know that cigarettes cause 1 death for every million smoked. When we consider that trillions of cigarettes are smoked every year, it is no surprise that cigarettes are predicted to cause nearly a billion deaths in the 21st century.

With processed meat, the WHO report estimates an 18% increased risk of colorectal cancer for every 50 grams per day of processed meat consumed – the amount of meat in a regular hotdog. In one large summary study reviewed by the WHO, the risk was seen to increase linearly with increasing consumption until one ate 140 grams of processed meat per day.

In America, nearly 5% of individuals will develop colorectal cancer over their lifetimes. It is the second leading causes of cancer-related deaths and the third most common type of cancer in men and women. The cancer is so common that the government recommends every adult over the age of 50 to be regularly screened for colorectal cancer. With statistics like this, it is hard to ignore the WHO’s conclusions.

The WHO estimates that 34,000 cancer deaths per year across the globe are attributable to eating processed meat. Although this number is smaller compared to the damage inflicted by cigarettes, it is still a significant issue to those getting colorectal cancer from eating processed meat. Whether its cigarettes or bacon, it is prudent to think about what we put in our mouths.

Several years ago, when I was only a first year medical student, I started out on a research project to find out why so few patients – specifically minorities – with kidney failure end up getting a kidney transplant. Research abounds on the topic, but we went ahead anyways mostly to flesh out details on minority care and to have solid proof that the problem exists in our own backyard. Our findings were eventually published in Transplantation – a respectable journal in the field.

At the end of our article, we thought about writing a familiar refrain: more research is needed on the subject to better understand it. But we didn’t. Our findings only added to an already sizable body of knowledge about a known problem; doing more research wasn’t going to solve it. Sure – additional research may be beneficial, but it would have come at a cost and may have only been marginally helpful. Given finite resources, as certainly within medicine, every action is subject to an opportunity cost; in the case of additional research, the opportunity cost could be taking those same resources and using them towards an intervention. Additional research is also subject to decreasing returns to scale. In other words, our findings weren’t as useful as the first person to ever describe it. And additional papers may not be as helpful as ours, unless they add some twist that has not previously been looked at (like minority care, as in our case).

Instead, we ended our article writing, “… more extensive educational campaigns … may allow a greater patient access to preemptive waitlisting and … transplantation.” Still we didn’t feel this was enough. Our paper showed that even in our own community patients were actively receiving substandard care. Only a few patients were being transplanted before starting dialysis (avoiding dialysis all together is the best). And, a large number of patients – specifically minorities – were spending months – even years – on dialysis (if you can’t avoid going on dialysis before a transplant, keep it as short as possible). So, we decided to implement an “intervention”.

Selecting an “intervention” and translating it into a final product was not easy and took years (for some perspective, I am now a third year resident). With the help of $15,000 in funding and skills from our transplant center, we made a trilingual video to educate end stage renal disease patients in the South Florida community about the benefits of a transplantation and how they can get one. Educating patients is usually a safe bet in terms of improving care. However, skeptics may want additional research showing that education works, which can be helpful but can also consume precious resources that could otherwise be used toward an intervention. Not that we needed it, but a paper published showed that making patients aware about kidney transplantation – as anyone would guess – increases awareness about kidney transplantation.

Our videos are available on YouTube in English, Spanish, and Creole to cater to the large number of Hispanic and Haitian patients with kidney disease in our community. Although the videos provide information specific to South Florida residents, we encourage others throughout the world to use them to deliver the main message about the benefits of transplantation. Collectively, the videos have a limited number of views at the moment, but we hope this number grows.

We also hope that these videos are an inspiration to others to effect practical change in other areas of medicine that so urgently need physician leadership and action. Additional research is always helpful, but is subject to decreasing returns to scale and opportunity costs. Sometimes, the best course may be turning those research findings into actionable change – even if you are only a medical student.

Acknowledgments: This project would not have been possible without the important contributions from Dr. Alayn Govea, Wei Yang, Hadi Kaakour, Dr. Giselle Guerra, Dr. Warren Kupin, Dr. Gaetano Ciancio, Dr. Oliver Lenz, Novartis, the Miami Transplant Institute, the University of Miami, and Jackson Memorial Hospital.

Several weeks ago, I was running late to my afternoon clinic. Literally, I could not move my feet fast enough. Reminiscent of 1990’s childhood computer games, my Oregon Trail tempo was somewhere between strenuous and grueling. Lunch in hand, I slid into clinic just as the nurse was readying the chart of my first patient. I stuffed my lunch into the desk drawer, read the name off the chart, and called him into my room. The encounter proceeded as usual. I sauntered through the patient’s complaints with ease until we came to the subject of his diet – something I attempt to discuss with every patient. As I broached the subject with an inquiry into the quantity of fruits and vegetables he ate, I was rebuffed.

“How many fruits and vegetables do you eat? Doctors have the worst diets!”

I bristled and was surprised that my patient had kept the pulse of my profession’s dietary discretions. This was the first time the proverbial (dining) table had been turned on me. And for good reason, my lunch, quietly ensconced in the desk drawer, was a personal pizza. Adorned with cheese and overflowing with fat, calories, and cholesterol. So delicious yet so un-doctor like. Never did I regret purchasing a pizza more than that day – and I hadn’t even eaten it yet. Unsure if I was sensing a poor coping mechanism or he smelled my pizza, I brandished my defense: I eat lots of fruits and vegetables as a vegetarian (but I may eat a pizza “once in a while”). Of course, I could have invoked that pizza is a vegetable, like Congress did back in 2011, but I didn’t want to entangle myself further1. Also, I didn’t dare reveal my pizza tucked away lest losing all credibility.

Straddling hypocrisy and Hippocrates, I counselled appropriately. The counselling, coming from my mouth, went into his ears. And mine. 69% of American adults are overweight or obese2. Physicians – who by default are adults unless you are Doogie Howser- are not far behind, trailing at a rate of 44% according to the Physicians Health Study3. And these numbers don’t take into account those of us who are “skinny fat,” like myself. My BMI is 23.9, but it used to be lower. Since starting college, I have gained nearly 15 pounds – half of which occurred during medical school and residency. In a study of military residents, the nascent physicians gained an average of 4 pounds, and that’s despite all the pushups they were doing4. Although I can readily hide my adiposity with a loosely tucked shirt, I know I am overweight for me. And I have gained more than G.I. Joe, PGY-3.

Whatever pressures that led me to gain weight probably won’t go away when I get out of residency or fellowship. And my specialty (internal medicine) is not alone. Being overweight or obese affects all specialties. According to Medscape’s Physician Lifestyle Report of 2014, general surgeons have the highest rates of being overweight or obese – approaching 50%5. Family practitioners are a close second. Dermatologists come last overall. Even among internal medicine subspecialties, gastroenterologists are the heaviest and allergists the lightest.

Things get really interesting when we start looking at how other physicians’ own health and habits affect patient interaction. We don’t judge a book by its cover, but patients judge their physician by his or her size. In one study, patients reported more mistrust of physicians who were overweight or obese, were less inclined to follow their medical advice, and were more likely to change providers if the physicians was overweight or obese6! Before judging our patients for their insensitivity, we should pause. Wouldn’t we instinctively distrust a broke financial advisor despite a litany of credentials?

As much as we would like to keep our personal and professional lives separate, they might be more intertwined than we think. Obese and overweight physicians are less likely to engage in conversations about lifestyle and are less likely to value the importance of physicians being “role models by maintaining [a] healthy weight” and by “exercising regularly7.” Obese or overweight physicians may not bring up these issues because their patients, as has been shown, may not take them credibly.

Since Wells et al. published their landmark findings in JAMA in 1984, we also know that physicians who live healthier lives (regardless of their BMI), counsel more frequently and more aggressively8. This has been confirmed repeatedly, and has even been shown in medical students9,10. Exercising and eating right not only have salutatory effects for yourself but inform the lifestyle narrative you provide to your patients. Understanding how important and difficult these changes are is just as important as the counselling itself. Saying what has worked for you individually – and not as a physician – ironically establishes a closer relationship with patients and provides more meaningful advice than tactlessly saying, “You are fat!” which I have seen other physicians do when I was a medical student.

Passing judgement is taboo. We are vulnerable to same pitfalls, tastes, and blithe overeating as our patients, if not more. Doctors, like patients, make nearly 200 food decisions daily. We are part of a profession that is fraught with pizza-plated, educational lunches and chocolate mousse-musts at dinner meetings. In the September 2012 issue of JAMA, Lesser et al. likened the universality of our poor dietary choices in medicine to smoking amongst physicians decades ago11. The parallels to smoking continue. If you are to broach the subject of weight loss or lifestyle change, the Five “A’s” – Ask, Advise, Assess, Assist, and Arrange – should serve as a guide12. They worked for smoking and they can work for eating and exercising. Doctors who regularly advise patients to be healthier had increases in motivation and confidence to change. Doctors, like patients, make nearly 200 food decisions daily13.

What works for us will likely work for our patients. For me, I watch calorie contents, eat whole foods (like fruits and vegetables and not processed foods), eschew meat, exercise (nearly) everyday, and make my own meals. I don’t lie about my habits but do tell them my goals. I tell my patients to make incremental changes that are realistic for themselves and to set their own goals. And, I also try not to bring pizza to the clinic, even if it is hidden in the desk drawer.

With all the talk of it being difficult to be a doctors – something I have published on before, being a patient is not easy either1. My disease: kidney stones. Let’s make no mistake; I am fortunate enough to have never had cancer, been in a disabling car crash, or dealt with any actually serious malady that other people have had (including my friends), but experiencing medicine from the other end was an eye-opening and unnecessarily cumbersome experience that gave me a new appreciation for my patients.

The process of being a patient hadn’t always been difficult. In fact, it was fairly straight forward when I was a child and still under my parents’ insurance plan. Having a physician-father also helped in navigating my disease and the healthcare system. Being a patient couldn’t have been easier. Not having to worry about copays and preferred providers, I could focus on my disease.

My first brush with having a kidney stone came as a surprise. I still remember the moment: I was eating lunch in the English room during the 11th grade. And then I was supine on the reading couch cringing from unbearable flank pain. My first thought was indigestion, but as the pain exploded past 10 on the 10-point scale, I realized I had something more sinister going on. My mother picked me up from school and took me to the emergency room. They told me I passed a kidney stone. I got the care I needed and that was it.

Now in my residency, I had a recurrence and the experience was much different. For my 29th birthday in July, I spent the day out on a boat with maximal sun exposure. Replacing water with beer – a known risk factor for kidney stones – and being subject to an unforgiving sun, my stones re-emerged, literally. Instead of having the tell-tale renal colic, I had persistent blood in my urine for the week following my afternoon soiree. I knew that these Goldilock-sized stones – not too big to obstruct my ureter and render me infantile, not too small to go completely unnoticed, but just big enough to cause some bleeding – were the cause because I had it first present this way in medical school. My primary care physician then, who after doing a few tests, told me it was nothing to worry about it and to drink water. I forgot to drink water and was now worrying. I was particularly worried because the bleeding went on for days – as opposed to just once or twice in medical school. Again, I needed those “few tests” to ensure I was still O.K. I needed to see my primary care physician.

I tried to make an appointment. Easier said than done. According to my employer, my insurance was no longer contracted with my previous primary care physician at the University of Man Hospitala. The change had preceded my hematuria by only a matter of weeks; I didn’t even have a chance to find a new primary care physician. I attempted to find a new physician, but who? Who does my insurance take? I called My Insurance and they directed me to their website which included more than 1,000 providers in a 15 mile radius based on my zip code. Narrowing this down to a 5 mile radius produced 427 results. Who do I call? I called a reputable and prominent facility near me: Mount Everest Medical Center. The first time I called they said they take My Insurance and connected me to “scheduling” where no one answered after waiting for ten minutes (an incredibly long period of time when you are the one waiting on the other end listening to a pre-recorded message on loop). I called again, no answer even from the operator. I called again the next day and they said they didn’t take my insurance. I called for a fourth time and same story – they don’t take my insurance despite what My Insurance’s website says. I gave up on Mount Everest Medical Center.

I went back to My Insurance’s website and now had 426 results to sort through. With each hematuric day, I grew weary of the blood and the listings on the website. Clicking through, I found my original primary care physician at the University of Man Hospital. I called the office of my primary care physician to see if they were listed on the website erroneously, and they said they still took my insurance. An insurance agent from My Insurance verified this. But the insurance representative at my employer was adamant that I could not go there. I threw my proverbial hands up in the air and decided to make an appointment regardless of the provider was “in-network” or “out-of-network.” I thought that I will know for sure if they are covered or not when I get a bill in the mail.

“The next appointment we have available for you is in six weeks.”

I told her I couldn’t wait that long.

“Have you thought about going to the emergency room?”

“Yes, I have but this is not an emergency.” I’ve worked in an emergency room. Me peeing blood feels like an emergency but doesn’t compare to the guy having a heart attack, the mother about to give birth, the baseball player with a broken finger, or the family of three that’s in a car accident. My problem is urgent. Not emergent. Emergency rooms are for emergencies.

Thinking about this for a few more days and realizing the predicament I was in, I knew that I wouldn’t be seen any faster as a new patient with any primary care provider within a 15 mile, let alone 5 mile, radius. I was one of the 62 million Americans without adequate access to a primary care physician2. Even more ironic, I am a physician myself and am surrounded by doctors. During this time, I even treated a patient with kidney stones. His stones had progressed to the point that he had obstructed his kidney and needed urgent decompression. He, like me in high school, went to the ER because he was bed bound from severe pain. In the back of my head, I couldn’t stop wondering was this happening to me – perhaps silently? Although completely silent stones are uncommon, they can cause partial or complete obstruction in up to 20% of patients3. Was I having silent obstruction? Would I be destined to a life of chronic kidney disease or, worse, kidney failure? Of all the causes of kidney failure, stones are the cause only 2% of the time. When considering that kidney stones affect 5% of the entire population, the total number of patients succumbing to kidney failure from stones is quite small4. As the days and blood passed, logic waned and hypochondria took over. With nephrology being my ultimate field of study and choice of specialty, I found it ironic that the physician-turned-patient was now beset by the very disease he had been studying.

And, I was not the first physician to self-diagnose his own disease of study. Armand Trousseau – famous for Trousseau’s sign of malignancy – found his namesake sign on himself when he had pancreatic cancer. And of course, generation after generation will remember Leonid Rogozov – the Russian surgeon who diagnosed himself with appendicitis while on an Antarctic research expedition and performed his own appendectomy5. Although only a resident, I knew the tests that I need to be done – after all, I had ordered them countless times for my patients. Yet, self-prescribing and self-treating are taboo. According to the most recent edition of the American College of Physicians Ethics Manual,

Except in emergent circumstances when no other option exists, physicians ought not care for themselves. A physician cannot adequately interview, examine, or counsel herself; without which, ordering diagnostic tests, medications, or other treatments is ill-advised6.

For urgent problems, there are urgent care centers, and some of them are covered by My Insurance, but they are only open during normal business hours – when I am at work. I suppose I could have taken a day off at work for the issue, but what if they weren’t able to do the blood work or imaging on the same day? Would I have to come back on different days for both the blood work and the imaging? Would I have to come back a third or fourth time for the results? How many times would I have to take off work? Anyone who has a full-time job understands my predicament. And now after being in the predicament myself, I better understand the hurdles my working patients have to overcome to see me during my business-hours-only clinic.

There are after-hours urgent care centers near me. But finding which ones were close by, covered by my insurance, open during business hours, and had same-day imaging and blood-testing available became a time-consuming and administrative nightmare. After much thought, I realized that I just needed any physician to order the most basic of tests. Once I had the prescriptions, I could have it done at the hospital I worked at before or after my shifts and have it covered by my insurance. Since I couldn’t write the prescriptions myself, I called a friend – a friend who happened to be a physician – to do it. And he did. Since the first episode of hematuria, it took me nearly three weeks to get a prescription for an ultrasound and blood work to check my kidney function and another 1-2 weeks to complete them and get the results, all of which were normal.

It was not an optimal choice, but perhaps the easiest solution for me. Although I did not self-prescribe and self-treat, in theory it is what I did. My physician-friend trusted my judgement and ordered the benign tests under his name using my judgement. I was not in the same situation as Leonid Rogozov, but I was becoming increasingly impatient and frustrated with the locating and seeing a primary care physician. What if I weren’t a college-educated, health-literate, English-speaking, American-born, middle-class physician with physician-friends? What if I didn’t have health insurance or couldn’t get the imaging and blood work at the same place as my employment? How does everyone else without all these advantages navigate the system and obtain healthcare? Maybe it is an urgent care facility requiring several half-days of missed work. Or maybe it is an emergency room visit followed by a hefty bill or two laterb. Or worse, maybe it is accepting defeat and letting diseases thrive unfettered. Or maybe it’s my expectations that healthcare should come easily?

Again, I have to state that I only had kidney stones. I can’t imagine what it is like to require chronic treatment for a serious illness like chemotherapy or repeated surgeries. It reminds of a statement one of my healthier, pentagenarian patients told me about after he repeatedly declined to have any form of colorectal cancer screening, which is recommended as routine for all over the age of 50. “I don’t want to spend the rest of my afternoons dealing with lab results, insurance companies, and doctor visits like all the rest of my friends my age,” he reasoned. Although most people don’t refuse screening so adamantly and most have normal cancer screening results, my patient was unmoved. I, however, was moved. His statement introduced something I had never thought about before: medicine, and the insurers of it, can so cumbersome that it inhibits healthcare.

Despite my advantages in navigating the health-care system, it still took me nearly three weeks to get the orders I needed and five weeks to get the results – which I obtained the way my patients do when they want a copy: through medical records. The process of getting my blood work done, having my ultrasound done, and retrieving my results was a time-consuming process that required patience and determination.

I knew what I did was not ideal, but it is not uncommon. Others have documented it regarding varying circumstances7,8. There are merits to having a friend that is a physician or, in some cases, your physician. The very same American College of Physicians Ethics Manual that I cited earlier acknowledges this. Read the excerpt (specifically the last two sentences):

Physicians should usually not enter into the dual relationship of physician–family member or physician-friend for a variety of reasons. The patient may be at risk of receiving inferior care from the physician. Problems may include effects on clinical objectivity, inadequate history-taking or physical examination, overtesting, inappropriate prescribing, incomplete counseling on sensitive issues, or failure to keep appropriate medical records. The needs of the patient may not fall within the physician’s area of expertise. The physician’s emotional proximity may result in difficulties for the patient and/or the physician. On the other hand, the patient may experience substantial benefit from having a physician-friend or physician–family member provide medical care, as may the physician. Access to the physician, the physician’s attention to detail, and physician diligence to excellence in care might be superior [emphasis added] 6.

I did not gain any additional benefit from having the prescriptions written through my physician-friend other than simply having them. But having the tests done was what mattered the most. I know I can’t do this continually, but it allowed me enough time to find a primary care physician at a time that was convenient for me. As such, I called back my original primary care physician and scheduled an appointment within two weeks. They initially tried to give me an appointment months away, but I pestered and pleaded, and they added me on as an “over-book.” When my visit came, I did have to wait nearly two hours past my appointment time to be seen.

After nearly six weeks from the original episode of hematuria, I saw my primary care physician. My copay was $15, and I haven’t received a supplemental bill in the mail. Yet. I also haven’t had any more instances of bleeding in weeks. However, things could change, and I may still be charged in full for the visit if my insurance truly doesn’t cover my primary care physician. My primary care physician agreed that my blood work (creatinine) and ultrasound were normal. But he referred me to a stone specialist and ordered a special urine test for people with recurring kidney stones. The urine test is, of course, not provided by the laboratory that is contracted with My Insurance. And so, the saga continues…

Footnotes:

Names of all health-care establishments have been fictionalized.

While in medical school, I went to the ER after injuring my arm. In total I received three bills, one was the deductible up-front. The second bill included the items the insurance company decided not to cover. And finally the third bill was for the services of the ER physician himself who was contracted separately from the ER. I am surprised that the nurse, nurse tech, janitor, plumber, line cook, and electrician didn’t also send me individual bills for their services during my brief 5 hour stay in the ER.